Superficial Endometriosis Research Articles

Location Matters: Likelihood of Superficial Endometriosis by Anatomic Site

<h3>Study Objective</h3> Compare anatomic site of visual and histopathologic endometriosis. <h3>Design</h3> Prospective clinical study. <h3>Setting</h3> Tertiary-care, academic medical center. <h3>Patients or Participants</h3> Surgical evaluation of 77 patients for suspected endometriosis by high-volume endometriosis surgeons. <h3>Interventions</h3> Documentation of visually present or absent endometriosis by anatomic site (left pelvic sidewall, left uterosacral ligament, right pelvic sidewall, right uterosacral ligament, posterior cul-de-sac, and bladder) followed by complete pelvic peritonectomy and pathologic evaluation. <h3>Measurements and Main Results</h3> Among all specimens with histopathology of endometriosis, the rates by anatomic site were 33.6% posterior cul-de-sac, 24.2% left pelvic sidewall, 18.4% right pelvic sidewall, 9.8% bladder, 7.4% left uterosacral ligament, and 6.6% right uterosacral ligament. For anatomic sites with visually suspected endometriosis, histopathologic diagnosis was confirmed in 53.4% posterior cul-de-sac, 49.4% left pelvic sidewall, 41.4% right pelvic sidewall, 60.9% bladder, 50% left uterosacral ligament, and 46.2% right uterosacral ligament (p<0.001). Sensitivity by anatomic site was 72.1% posterior cul-de-sac, 67.7% left pelvic sidewall, 61.7% right pelvic sidewall, 56.0% bladder, 84.2% left uterosacral ligament, and 70.6% right uterosacral ligament. Bladder had the highest positive predictive value (60.9%) while right pelvic sidewall had the lowest (41.4%). Specificity was consistent between anatomic sites (74.8% posterior cul-de-sac, 74.6% left pelvic sidewall, 77.7% right pelvic sidewall, 92.8% bladder, 72.4% left uterosacral ligament, 76.7% right uterosacral ligament). Negative predictive value was also consistent between anatomic sites with the highest for left uterosacral ligament (93.3%) and lowest for left pelvic sidewall (86.3%). <h3>Conclusion</h3> Endometriosis was most frequently found in the posterior cul-de-sac and least frequently on the uterosacral ligaments. Correlation between visual and histopathologic diagnosis was 41.4%-60.9%, indicating that visually detecting endometriosis intraoperatively is frequently inaccurate and normal-appearing peritoneum does not rule out disease. Complete peritonectomy may be warranted to prevent missing disease, but if not preferred, removal of the posterior cul-de-sac and left pelvic sidewall should be considered given these locations had the highest rates of endometriosis.

Effectiveness of ultrasound for endometriosis diagnosis.

Endometriosis is a chronic benign gynaecological condition characterized by pelvic pain, subfertility and delay in diagnosis. There is an emerging philosophical shift from gold standard histopathological diagnosis through laparoscopy to establishing diagnosis through noninvasive imaging. The ENZIAN classification system was updated in 2021 to be suitable for both diagnostic imaging and laparoscopy. The accuracy of transvaginal ultrasound (TVUS) in diagnosing endometriosis varies depending on location of the lesion. A recent international pilot study found that when ultrasound is performed in accordance with the IDEA consensus, a higher detection of deep endometriosis is seen, with an overall sensitivity of 88% and specificity of 79% compared with direct surgical visualization. Although ultrasound can detect adenomyosis, deep endometriosis and endometriomas, it is not possible to reliably detect superficial endometriosis. In the instance of a negative ultrasound with persistence of symptoms despite medical therapy, laparoscopy should be considered for diagnosis and treatment.

Association Between Laparoscopic Appearance of Superficial Endometriosis, Positive Histology, and Systemic Hormone Use

To assess the association between laparoscopic appearance of superficial endometriosis (SE) lesions, histopathology, and systemic hormone use. Retrospective study SETTING: Tertiary care academic medical center PATIENTS: We identified 266 women who underwent laparoscopic surgery at an endometriosis center with excision of lesions consistent with possible superficial endometriosis between 09/2015 and 11/2018. Appearance of the peritoneal lesions was confirmed with review of surgical videos and correlated with each pathology specimen. Lesions were dichotomized on positive or negative pathology assessment. All pathology positive lesions were further dichotomized by hormone use within one month of surgery. A total of 841 lesions were biopsied from included subjects during the study period. Of those, 251 biopsies were negative and 590 were positive for endometriosis on pathology assessment. Lesions had significantly higher odds of positive histology when they were red (OR 1.70, 95%CI 1.17-2.48), white (OR 1.99, 95%CI 1.47-2.70), blue/black (OR 2.98, 95%CI 2.00-4.44), or puckering (OR 9.78, 95%CI 2.46-38.91) in appearance. The following combined characteristics had significantly higher odds of positive histology: white and blue (OR 5.98, 95%CI 2.97-12.02), red and white (OR 2.22, 95%CI 1.38-3.56), red and blue (OR 4.11, 95%CI 1.83-9.24), and clear and white (OR 8.77, 95%CI 1.17-66.02). Among positive biopsies, those with hormone exposure were more likely to have clear lesions than those without hormone use (OR 3.36, 95% CI 1.54-7.34), and were 2.89 times more likely to have clear and white lesions (95% CI 1.07-7.85). While lesions suspicious for endometriosis may have differing rates of positive pathology based on appearance, no lesion characteristic was able to exclude the possibility of endometriosis. Additionally, hormone use may influence lesion appearance at time of surgery, with clear lesions more prevalent. These data have implications for appropriate identification of endometriosis at the time of laparoscopy to ensure accurate diagnosis and complete treatment of disease.

Diagnostic accuracy of transvaginal ultrasound for detection of endometriosis using International Deep Endometriosis Analysis (IDEA) approach: prospective international pilot study.

To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in predicting deep endometriosis (DE) following the International Deep Endometriosis Analysis (IDEA) consensus methodology. This was an international multicenter prospective diagnostic accuracy study involving eight centers across six countries (August 2018-November 2019). Consecutive participants with endometriosis suspected based on clinical symptoms or historical diagnosis of endometriosis were included. The index test was TVS performed preoperatively in accordance with the IDEA consensus statement. At each center, the index test was interpreted by a single sonologist. Reference standards were: (1) direct visualization of endometriosis at laparoscopy, as determined by a non-blinded surgeon with expertise in endometriosis surgery; and (2) histological assessment of biopsied/excised tissue. Surgery was performed within 12 months following the index TVS. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios (LR+ and LR-) of TVS in the diagnosis of DE were calculated. Included in the study were 273 participants with complete clinical, TVS, laparoscopic and histological data. Of these, based on histology, 256 (93.8%) were confirmed to have endometriosis, including superficial endometriosis, and 190 (69.6%) were confirmed to have DE. Based on surgical visualization, 207/273 (75.8%) patients had DE. For DE overall, the diagnostic performance of TVS based on surgical visualization as the reference standard was as follows: accuracy, 86.1%; sensitivity, 88.4%; specificity, 78.8%; PPV, 92.9%; NPV, 68.4%; LR+, 4.17; LR-, 0.15, and the diagnostic performance of TVS based on histology as the reference standard was as follows: accuracy, 85.9%; sensitivity, 89.8%; specificity, 75.9%; PPV, 90.4%; NPV, 74.6%; LR+, 3.72; LR-, 0.13. Using the IDEA consensus methodology provides strong diagnostic accuracy for TVS assessment of DE. We found a higher TVS detection rate of DE overall than that reported by the most recent meta-analysis on the topic (sensitivity, 79%), albeit with a lower specificity. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

OP06.04: Ultrasound evaluation of uterosacral ligament thickness for predicting superficial endometriosis

OP06.04: Ultrasound evaluation of uterosacral ligament thickness for predicting superficial endometriosis

Surgical techniques for excision of juvenile cystic adenomyoma

To review causes of pelvic pain among adolescents and discuss surgical techniques for safe and effective resection of juvenile cystic adenomyomas. Case report. Academic medical center. We present a 16-year-old patient with chronic pelvic pain and ultrasound evidence of a 2.4 cm adenomyoma. The lesion was thought specifically to represent a juvenile cystic adenomyoma, defined as a cystic lesion >1 cm occurring in women younger than 30 years with severe dysmenorrhea that is distinct from the uterine cavity and surrounded by hypertrophic myometrium. Given minimal relief from medical therapy and high suspicion for coexistent endometriosis, our patient elected to undergo laparoscopic resection of adenomyoma and excision of pelvic lesions. Preoperative considerations discussed in this video include imaging to identify the location of the lesion and adjacent structures, such as the uterine vessels, discontinuation of gonadotropin-releasing hormone agonist for adequate intraoperative visualization, and the high likelihood of encountering endometriosis at operation. We review the following surgical techniques: maximize visualization with the use of a uterine manipulator and temporary oophoropexy, optimize hemostasis via temporary uterine artery ligation and control of collateral blood vessels, complete ureterolysis, meticulous enucleation of adenomyoma, and excision of coexistent endometriotic lesions. Surgical findings demonstrated a 2 cm lesion along the left lower uterine segment and red-brown lesions along bilateral ovarian fossa, pathologically confirmed as adenomyoma and superficial endometriosis, respectively. This video presents strategies for safe and effective adenomyoma resection and treatment of refractory chronic pelvic pain in an adolescent.

What is the accuracy of transvaginal ultrasound for endometriosis mapping prior to surgery when performed by a sonographer within an outpatient women's imaging centre?

This study aimed to assess the accuracy of transvaginal ultrasound (TVUS) for the mapping of endometriosis before surgery when performed by sonographers in an outpatient women's imaging centre. A prospective longitudinal cohort study was performed. The study group comprised of 201 women who underwent a comprehensive TVUS assessment, performed by a sonographer. Laparoscopy was performed as the reference standard. Complete TVUS and surgical data were available for 53 women who were included in the final analysis. Endometriosis was confirmed at a surgery in 50/53 (94.3%) participants, with 25/53 (47.2%) having deep endometriosis (DE) nodules and/or endometriomas present. TVUS for mapping of DE had an overall sensitivity of 84.0%, specificity of 89.3%, PPV of 87.5%, NPV of 86.2%, LR+ of 7.85, LR- of 0.18, and accuracy of 86.8% (P < 0.001). Ovarian immobility had poor sensitivity for detecting localised superficial endometriosis, DE, adhesions, and/or endometriomas (Left = 61.9% and right = 13.3%) but high specificities (left = 87.5% and right = 94.7%). Site-specific tenderness had low sensitivities and moderate specificities for the same. All soft markers of endometriosis failed to reach statistical significance except for left ovarian immobility (P = <0.001). Sonographers well experienced in obstetric and gynaecological imaging, working in an outpatient women's imaging setting can accurately map DE; however, the performance of soft markers for detection of SE was poor.

Surgical techniques for excision of juvenile cystic adenomyoma

The objectives of this video are to review causes of pelvic pain among adolescents and to discuss surgical techniques for safe and effective resection of juvenile cystic adenomyomas. We present a 16-year-old patient with chronic pelvic pain and ultrasound evidence of a 2.4cm adenomyoma. The lesion was specifically thought to represent a juvenile cystic adenomyoma (JCA), defined as a cystic lesion >1cm occurring in women under 30 years with severe dysmenorrhea that is distinct from the uterine cavity and surrounded by hypertrophic myometrium. Given minimal relief from medical therapy and high suspicion for co-existent endometriosis, our patient elected to undergo laparoscopic resection of adenomyoma and excision of pelvic lesions. Preoperative considerations discussed in this video include imaging to identify the location of the lesion and adjacent structures such as the uterine vessels, discontinuation of GnRH agonist for adequate intraoperative visualization, and the high likelihood of encountering endometriosis af the time of surgery. We review the following surgical techniques: 1) maximize visualization with use of a uterine manipulator and temporary oophoropexy, 2) optimize hemostasis via temporary uterine artery ligation and control of collateral blood vessels, 3) complete ureterolysis, 4) meticulous enucleation of adenomyoma, and 5) excision of co-existent endometriotic lesions. Surgical findings demonstrated a 2cm lesion along the left lower uterine segment and red-brown lesions along bilateral ovarian fossa, pathologically confirmed as adenomyoma and superficial endometriosis, respectively. This video presents strategies for safe and effective adenomyoma resection and treatment of refractory chronic pelvic pain in an adolescent.

Spiders and mushrooms: Reporting bowel endometriosis shape on preoperative MRI to flag surgical complexity.

Preoperative imaging of patients with endometriosis allows adequate counselling, referral to appropriate centres of expertise and workforce planning. The objective of this study was to assess the feasibility of simplified three-category preoperative endometriosis MRI morphological descriptors to predict subsequent surgical management. A single-centre observational study in 76 patients (median age 38 years, range 18-55) with preoperative endometriosis mapping MRI between 1 Jan 2015 and 31 Dec 2019. MRI studies were prospectively re-read blind-to-surgical outcome to categorise rectosigmoid morphology as normal, spider-shaped (linear T2-dark fibrotic bands) superficial endometriosis or typical crescentic or mushroom-shaped deep infiltrating endometriosis (DIE). Bowel motility was similarly categorised as normal, tethered or distorted/fixed. The reference standard was subsequent surgery within 3 years of MRI, categorised as no bowel surgery, adhesiolysis only or more complex surgeries. Despite three-quarters of surgical cases having normal bowel morphology on preoperative MRI (72%, 55/76; 12% linear superficial endometriosis, 10% crescentic and 5% mushroom-shaped DIE) more than half showed bowel tethering (54%, 41/76) or distortion/fixation (10%, 8/76) and most patients underwent adhesiolysis (79%, 60/76). Complex surgery such as bowel resection, laparotomy conversion or complex adhesiolysis is predicted by morphology (crescentic or mushroom-shaped DIE, P < 0.001) and motility (tethered or distorted bowel, P = 0.002) descriptors. Comprehensive and clinically relevant diagnostic reporting does not have to be convoluted to have clinical impact: in our study population, categorising bowel morphology as normal, spider-shaped (superficial) or crescentic/mushroom-(DIE) shaped and motility as normal, tethered (superficial) or distorted/fixed (deep endometriosis) correlates to subsequent surgical complexity.

Peritoneal fluid progesterone and progesterone resistance in superficial endometriosis lesions.

Peritoneal fluid in ovulatory women is an ovarian exudate with higher estrogen and progesterone concentrations than in plasma. In the follicular phase, progesterone concentrations are as high as plasma concentrations in the luteal phase. After ovulation, estrogen and progesterone concentrations in the peritoneal fluid are 5-10 times higher than in plasma, both in women with and without endometriosis. The histologically proliferative aspect without secretory changes of most superficial subtle lesions is not compatible with the progesterone concentrations in the peritoneal fluid. Therefore, we have to postulate a strong progesterone resistance in these lesions. The mechanism is unclear and might be a peritoneal fluid effect in women with predisposing defects in the endometrium, or isolated endometrial glands with progesterone resistance, or subtle lesions originating from the basal endometrium: the latter hypothesis is attractive since in basal endometrium progesterone does not induce secretory changes while progesterone withdrawal, not occurring in peritoneal fluid, is required to resume mitotic activity and proliferation. Hormone concentrations in the peritoneal fluid are an important factor in understanding the medical therapy of endometriosis. The effect of oestro-progestin therapy on superficial endometriosis lesions seems to be a consequence of the decreased estrogen concentrations rather than a direct progestin effect. In conclusion, the peritoneal fluid, being a secretion product of the ovarian follicule, deserves more attention in the pathophysiology and treatment of endometriosis.

Evolution of Bowel Complaints after Laparoscopic Endometriosis Surgery: A 1497 Women Comparative Study

To assess to what degree can digestive symptoms improve after endometriosis surgery for different localizations. A comparative retrospective study employing data prospectively recorded in the North-West Inter-Regional Female Cohort for Patients with Endometriosis (CIRENDO) from June 2009 to November 2018. Two referral centers. A total of 1497 women undergoing surgery because of pelvic endometriosis were divided into 3 groups: superficial endometriosis (Group 1, n=396), deep endometriosis sparing the bowel (Group 2, n=337), and deep endometriosis involving the bowel (Group 3, n=764). Surgery for endometriosis. Preoperative and postoperative gastrointestinal symptoms were evaluated with standardized questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI) and Knowles-Eccersley-Scott-Symptom questionnaire (KESS). The degree of postoperative improvement in digestive symptoms was compared between the groups. The women in Group 3 were significantly symptomatic in terms of cycle-related gastrointestinal symptoms and scores of standardized questionnaires GIQLI and KESS. According to the 1-year postoperative evaluation, women in Group 3 experienced the most significant improvement in their gastrointestinal symptoms. Women with severe bowel symptoms and deep endometriosis infiltrating the bowel should be informed about the high probability of symptom improvement after the removal of bowel nodules. Conversely, in women without deep endometriosis, postoperatively, there is less improvement in baseline digestive complaints.

How Good Is the Surgeon Eye? Evaluating Histopathologic Diagnosis of Endometriosis Compared to Gross Visualization

<h3>Study Objective</h3> Evaluate the sensitivity and specificity of visual diagnosis of superficial endometriosis at the time of laparoscopy via comparison to final histopathologic evaluation. <h3>Design</h3> Prospective clinical study of women with pelvic pain who undergo laparoscopic pelvic peritonectomy for suspected endometriosis. <h3>Setting</h3> Tertiary-care, academic center. <h3>Patients or Participants</h3> All patients undergoing laparoscopic evaluation by high-volume endometriosis surgeons for the identification and excision of suspected endometriosis were screened from November 2020 to March 2021. Inclusion criteria included female patient >18 years old with pelvic pain suspicious for endometriosis and ability to provide informed consent. Exclusion criteria included evidence of deeply infiltrating endometriosis on preoperative deep pelvic ultrasound or identified intraoperatively. <h3>Interventions</h3> 43 patients underwent laparoscopic pelvic peritonectomy for suspected endometriosis and were included in analysis. <h3>Measurements and Main Results</h3> Final histopathologic diagnosis of endometriosis was detected in 32 patients (74.42%) in at least one location in the pelvis. Of the patients with positive histopathology for endometriosis, overall visual sensitivity and positive predictive value (PPV) were 100%. Endometriosis was correctly visually identified on lesions excised from the peritoneum in 100% of left pelvic sidewall, 83.3% of left uterosacral ligament, 75% of right pelvic sidewall, 66.7% of right uterosacral ligament, 81.5% of posterior cul-de-sac, and 71.4% of bladder. Of the patients with negative histopathology for endometriosis, overall visual specificity was 45% and negative predictive value (NPV) was 84%. Visual detection of endometriosis without final histopathologic confirmation was reported for 30% of left pelvic sidewall, 37.5% of left uterosacral ligament, 40% of right pelvic sidewall, 57.1% of right uterosacral ligament, 29% of posterior cul-de-sac, and 54.5% of bladder specimens. <h3>Conclusion</h3> Overall sensitivity, specificity, PPV, and NPV for the visual detection of endometriosis at the time of laparoscopy was 100%, 45%, 100%, and 84% respectively. This suggests a role for complete resection of the peritoneum during evaluation for endometriosis.

Immunolocalization of stem/progenitor cell biomarkers Oct-4, C-kit and Musashi-1 in endometriotic lesions.

Human endometrium harbors stem/progenitor cells (SPCs) that may contribute to the establishment of endometriosis when seeded outside the uterus. Oct-4, C-kit and Musashi-1 are some of the many proteins used to characterize SPCs, but their association with endometriosis is uncertain. In this study, specimens of normal endometrium (n = 12), eutopic endometrium from women with endometriosis (n = 9), superficial peritoneal endometriosis (SUP, n = 12) and deep endometriosis (DE, n = 13) lesions were evaluated for localization and intensity of immunostaining for Oct-4, C-kit and Musashi-1. The three markers were abundantly expressed in normal endometrium, eutopic endometrium from endometriosis patients, SUP and DE specimens. Oct-4 and C-kit expression did not vary across groups as regards intensity or frequency. C-kit staining signal was seldom detected in vascular endothelium of normal or eutopic endometrium from endometriosis patients; however, it was positive in 67% of the SUP lesions and in 25% of the DE lesions (p = 0.042). Musashi-1 was expressed in some endometriotic glands as cell clusters, but its signal was similar between the four types of tissue (p = 0.971) CONCLUSION: The wide distribution of Oct-4, C-kit and Musashi-1 in endometria of patients with and without endometriosis and in SUP and DE endometriotic lesions suggests that these markers are not suitable for the in situ characterization of endometrial SPCs and should not be taken as surrogates for the study of SPCs in the pathogenesis of endometriosis.

P–326 Presence of adenomyosis at MRI in endometriosis women negatively affect live birth chances in IVF cycles

Abstract Study question What is the impact of adenomyosis and its magnetic resonance imaging (MRI) characteristics on live birth rate (LBR) in endometriosis-affected women undergoing in-vitro fertilization (IVF) treatment? Summary answer Among women undergoing IVF, the presence of adenomyosis at MRI, and especially T2 high signal-intensity spots within the myometrium have a negative impact on LBR. What is known already: Adenomyosis is a frequent gynecologic disease. With the development of imaging technics for the diagnosis (notably MRI), several adenomyosis phenotypes have been described and fertility issues seem variable according to the lesions characteristics. Moreover, on IVF outcomes, controversial results have been found in studies assessing the impact of adenomyosis. What make the impact-assessment of adenomyosis on fertility issues even more difficult is the frequent association with endometriosis, another known risk factor of infertility. Some data suggested that adenomyosis could worsen IVF prognostics, however there is no clear consensus about the impact of the adenomyosis on IVF outcomes in endometriosis affected-women. Study design, size, duration This was an observational study including phenotyped endometriosis patients, aged between 18 to 42 years, who underwent IVF/intra-cytoplasmic sperm injection (ICSI) treatment in a tertiary care center, from June 2015 through July 2018.Only women who had performed a pelvic MRI during the pre-therapeutic ART work-up, were retained for this study. The MRI data were interpreted by radiologists who had expertise in gynaecological MRI. Participants/materials, setting, methods A continuous series of 202 endometriosis affected women was included. The women were followed until four ART cycles had been completed, until delivery or until discontinuation of treatment before the completion of four cycles. The primary outcome was the delivery of one or more live infant(s) after up to four IVF/ICSI cycles. Patients and MRI characteristics were compared between women who gave a live birth and those without live birth. Main results and the role of chance The mean age of the included population was 32.5 ±3.7 years. 90.1% (182/202) had deep infiltrating endometriosis whereas only 5.4% (11/202) and 4.5% (9/202) had respectively isolated ovarian endometriosis (OMA) and superficial peritoneal endometriosis (SUP). The presence of adenomyosis (internal and/or external lesions) was found in 71.8% (145/202) of included women. The cumulative live birth rate was 57.4% (116/202). Women that gave birth (‘live birth +’) were significantly younger, (33.3±4.1 vs 32.0±3.3 p = 0.026) and had significant better ovarian reserve parameters (AMH, AFC). The presence of adenomyosis (internal and/or external lesions) (76/116 (65.5%) versus 69/86 (80.2%), p = 0.022) and the presence of T2 high-signal intensity myometrial spots (27/116 (23.3%) and 37/86 (43.0%), p = 0.003) were significantly less frequently found in the group of women ‘Live birth +’. After multivariate analysis, the presence of adenomyosis (OR: 0.48 95% CI (0.29–0.99) p = 0.048) and the presence of T2 high-signal intensity myometrial spots (OR: 0.43 95% CI (0.22–0.86) p = 0.018) were independently found to be associated with a decrease in cumulative chances of live birth. Limitations, reasons for caution The inclusion of patients from our referral center could constitute a possible selection bias, as those women may have suffered from particularly severe forms of adenomyosis ± endometriosis. Wider implications of the findings: In women presenting endometriosis, the practitioner should perform an appropriate imaging work-up searching for adenomyosis, to identify prognostic factors and to plan the strategy of patient management in the setting of ART. Trial registration number NA

P–331 The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis

Abstract Study question Is there a classification for a complete mapping of endometriosis, including anatomical location, size of the lesions, and degree of involvement that can be used with both, diagnostics and surgery? Summary answer #Enzian classification improves in both, non-invasive diagnostic methods and surgical therapy for endometriosis as a universally usable classification system for all aspects of the disease. What is known already The most commonly used r-ASRM classification has certain limitations due to its incomplete description of DE, the complexity of the classification, and lack of reproducibility. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable for the description of DE. However, since it does not include peritoneal and ovarian lesions and lacks a description of tubo-ovarian adhesions, it has not gained full acceptance. A combination of classification with different systems such as r-ASRM, EFI score and Enzian, may complicate classification of the disease due to overlaps and time-consuming documentation. Study design, size, duration The result is a consensus of a panel of renowned clinicians (working group), gynaecological surgeons and sonographers with extensive expertise in diagnosis and therapy of endometriosis. A first draft was written in 2019 by a joint effort of the first and last author and sent to all working group members. Taking all comments into account, a revised draft was then sent to all coauthors and repeated until a consensus was reached (9 revisions). Participants/materials, setting, methods Criteria used to invite the experts to participate in this consensus process included their having significant peer-reviewed publications in the field of diagnosis and management of endometriosis. Main results and the role of chance Our current proposal is the first of its kind to universally describe superficial and deep endometriosis, ovarian endometriosis, adenomyosis and adhesions by using a classification system that can be applied by gynaecologists, surgeons, sonographers and radiologists following the same principles. The correlation between preoperative and surgical staging, on the basis of the Enzian scheme, allows for consistent and clear classification of endometriosis, especially DE. Endometriosis can be mapped completely with one single classification system enabling the use of one common language. Limitations, reasons for caution This classification system is anatomically logical and should be easy to use. Further studies are ongoing and are needed to provide proof for the applicability, reproducibility and accuracy of the #Enzian classification for the description of endometriosis. Wider implications of the findings: #Enzian classification now enabled better coverage of various endometriosis localizations. The possibility of using this system preoperatively as well as postoperatively within the framework of diagnostics offers clinicians a significant improvement in the care of patients with such a complex disease. Trial registration number Not applicable

P–310 Women with endometriosis achieve live birth after a similar number of embryo transfers independent of the endometriosis subtype

Abstract Study question How many embryo transfers are needed to achieve the first live birth in women with endometriosis depending on disease localisation? Summary answer The number of transfers needed to achieve live birth in women with endometriosis is independent from the disease’s subtype. What is known already Infertility is one of the leading symptoms in women with endometriosis. Endometriosis is also known to negatively impact in-vitro fertilization (IVF) outcome. A reduction of oocyte yield, especially of mature oocytes in women with endometrioma (OMA) and deep infiltrating endometriosis (DIE) has been shown. Inflammatory processes possibly affect folliculogenesis and oocyte development, maybe impeding embryo development and implantation. In contrast, even with fewer retrieved oocytes per cycle live birth rate was not affected. However, it is currently unknown if specific endometriosis subtypes could differentially affect IVF success. This would be relevant for a more targeted counseling regarding the treatment success. Study design, size, duration This is a single-center cohort study including women (N = 229) with embryo transfer cycles leading to live birth at the Bern University Hospital between 2010 and 2017. We only included women until they achieved the first live birth at our center. Participants/materials, setting, methods: We included 86 women with endometriosis and 143 women with male factor infertility serving as comparison group. We collected patient characteristics, details from the endometriosis surgery and reproductive treatment and outcomes from medical reports. We hierarchically classified the dominant endometriosis localizations as follows: deep infiltrating endometriosis (DIE, N = 21) &amp;gt; ovarian endometriosis (OMA, N = 35) &amp;gt; superficial peritoneal endometriosis (SUP, N = 30). We compared the number of embryo transfers needed to achieve a live birth. Main results and the role of chance Women with endometriosis were older (34.5 ± 3.9 years) than women from the control group (33.4 ± 3.9), p = 0.03. Body-mass-index, previous parity or Anti-Mullerian hormone level did not differ between the groups SUP, OMA, DIE or the comparison group. The number of necessary embryo transfer cycles to achieve a live birth did not differ between women with SUP (3.4 ± 2.6 embryo transfers), OMA (2.9 ± 2.0), DIE (3.0 ± 2.4) and the comparison group (2.9 ± 2.2), p = 0.59. IVF is beneficial in women with endometriosis, especially when OMA and/or DIE affect mobility of tubes and ovaries and spontaneous pregnancy is unlikely or impossible. This could account for the equal number of transfer cycles needed to achieve a live birth in women with OMA compared to the comparison group, even though the women with endometriosis were of older age. This is reassuring when counseling women with endometriosis. Limitations, reasons for caution We did not calculate cumulative pregnancy rate per cycle, because in Switzerland IVF treatment is at the patient’s own cost and therefore biased. We wanted to include all women with endometriosis, so fresh and thawing cycles were included. Women from the comparison group had no surgical exclusion of endometriosis. Wider implications of the findings: Our study suggests that the endometriosis subtype does not determine the embryo transfer success rate after IVF and therefore is less relevant for counseling. Individualized anti-inflammatory treatment before embryo transfer might positively affect the cycles’ outcome. Studies with a larger sample are required to be more conclusive on this issue. Trial registration number BASEC 2015–00235

MRI sliding sign: Using MRI to assess rectouterine mobility in pelvic endometriosis.

Surgical excision of deep infiltrating endometriosis (DIE) is complex and associated with morbidity. Diagnostic imaging plays an important role in the preoperative workup. We sought to determine the utility of single sagittal T2-weighted MRI motion sequence in the preoperative assessment of pelvic mobility in patients with endometriosis. An observational study at a single tertiary public referral centre in Australia. Eighty-one MRI studies from 1 May 2019 to 3 December 2019, were enrolled. Studies were included if they were performed to stage endometriosis, including a T2-weighted motion series, adequately covering a uterus, cervix and rectum. Fifty-seven studies met inclusion criteria. The reference standard was a contemporaneous transvaginal ultrasound (TVUS) reporting on pelvic organ mobility. Three subspecialist radiologists were then blindly asked to identify, on the cine loop: rectouterine immobility, superficial endometriosis (pelvic bowel adhesions), rectosigmoid Deep Infiltrating Endometriosis (DIE). Fleiss' Kappa assessed interobserver agreement. Consensus MRI sensitivity and specificity were estimated against the reference standard (TVUS). Median age was 35 years (range 19-51). Forty-three cases had a contemporaneous TVUS; 14 reporting a sliding sign, 29 with fixed pelves. Interobserver agreement was 'substantial' (k = 0.79) for absent MRI sliding sign and 'almost perfect' (k = 0.90) for absence of DIE. Consensus MRI had 90% sensitivity (95% CI 73-98%) for pelvic immobility at TVUS (absent sliding sign). Interobserver agreement and consensus MRI sensitivity were higher for adhesions and immobility than normal findings. An MRI motion sequence can identify patients with pelvic adhesions and immobility, helping determine surgical difficulty when TVUS is not diagnostic.

79 Non-invasive detection of endometriosis implants with MRI and patient reported outcomes

To understand the characteristics of patients with superficial endometriosis implants detected on MRI. A retrospective chart review of 10 years of MRIs noting “endometriosis” within the report. MRIs done by radiologists trained in detection of superficial endometriosis. There were 161 MRI reports over a 10-year period with 100 meeting criteria for MRI evidence of endometriosis and 50 with superficial endometriosis implants. Of the 100 patients, 50 had superficial implants; 18 patients had superficial implants only, 32 patients had other findings on MRI (e.g., endometriomas). In patients with superficial implants, 61% had one, 16% two, 6% three, and 16% innumerable implants noted on MRI. The most common location of superficial implants was the ovary (56%), followed by the abdominal wall (11%), peritoneum (6%), bladder (6%), and bowel (6%). The average age of patients with only superficial implants was 37 (SD = 7) and BMI was 26 (SD = 7). 28% were white, 11% black, 9% Asian, 52% were other. 55.6% had some medical comorbidity. There was no significant difference in race, age, BMI, and medical comorbidities, between the two groups. The most common medical comorbidity of the superficial cases was anxiety or depression (44.4%) followed by asthma (17%) and autoimmune disease (17%). Patients with only superficial implants were significantly more likely to have anxiety or depression (χ2 [1, N = 100] = 8.198, P < 0.01) than patients with additional MRI findings. MRI capabilities have now expanded to include detection of superficial endometriosis, but the characteristics of patients with these lesions is unknown. Our study has shown a substantial proportion (18%) of MRIs are now discovering only superficial lesions. These patients seem to be similar in demographics to those with other MRI findings, however in our population they were significantly more likely to have anxiety and depression.

Chronic Pelvic Pain Educational Experience Among Minimally Invasive Gynecologic Surgery Fellows and Recent Graduates: A Needs Assessment

Learning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP. The AAGL-Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options. Electronic survey. Not applicable. The survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years. Fifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a "good amount" of experience or "extensive" experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having "no" or "little" experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p=.002; recent graduates OR 1.5, p< .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p=.0021; recent graduates OR 1.5, p<.001), and the desire to incorporate the treatment of CPP into future clinical practice (current fellows OR 1.8, p=.0099; recent graduates OR 1.3, p=.0178). More than 80% (43/53) of current fellows indicated that they believed an expanded pelvic pain curriculum should be part of the FMIGS fellowship. This needs assessment of FMIGS fellows and recent graduates suggests that there are gaps between FMIGS curriculum objectives and current educational experiences, and that fellows desire increased CPP exposure. Expansion and standardization of the CPP educational experience is needed and could lead to increased focus on this disease process among subspecialty benign gynecologic surgeons.

Closing the communication loop between gynecological surgeons, diagnostic imaging experts and pathologists in endometriosis: building bridges between specialties.

Closing the communication loop between gynecological surgeons, diagnostic imaging experts and pathologists in endometriosis: building bridges between specialties.